Trauma, Fractures

Key Features

• Reduction of fractures in children can usually be accomplished by simple traction and manipulation

• Open reduction is indicated if a satisfactory alignment is not obtained

• Remodeling of the fracture callus generally produces an almost normal appearance of the bone over a matter of months

• Child abuse should be suspected when

  • Age of a fracture does not match the history given

  • Severity of the injury is more than the alleged accident would have produced

Clinical Findings and Diagnosis

• Epiphyseal separations

  • More common than ligamentous injuries in children since the ligaments of the joints are generally stronger than their associated growth plates

  • Radiographs should be taken whenever a dislocation is suspected in order to rule out epiphyseal fracture

  • Radiographs of the opposite extremity, especially for injuries around the elbow, are valuable for comparison

  • Fractures across the growth plate may produce bony bridges that will cause premature cessation of growth or angular deformities of the extremity

  • These bridges are due to trauma to the growth plate and can occur even with adequate reductions

• Torus fractures

  • Consist of "buckling" of the cortex due to compression of the bon

  • Most common in the distal radius or ulna

• Greenstick fractures

  • Involve frank disruption of the cortex on one side of the bone but no discernible cleavage plane on the opposite side

  • Bone ends are not separated, making these fractures angulated but not displaced

• Clavicle

  • Healing callus will be apparent when the fracture has consolidated

  • Unsightly lump will generally resolve over a period of months to a year via bone remodeling

• Supracondylar fractures of the humerus

  • Tend to occur in children age 3–6 years and are the most common elbow fracture in children

  • The proximity to the brachial artery in the distal arm creates a potential danger when dealing with these types of fractures

  • Absence of a distal pulse is a strong indicator of a secondary arterial injury

  • Swelling may be severe as these injuries are usually associated with a significant amount of trauma

Treatment

• Epiphyseal separations

  • Reduction of a fractured epiphysis should be done under anesthesia to align the growth plate with the least amount of force

  • Epiphyseal fractures around the shoulder, wrist, and fingers can usually be treated by closed reduction, but fractures of the epiphyses around the elbow often require open reduction

  • In the lower extremity, accurate reduction of the epiphyseal plate is necessary to prevent joint deformity when a joint surface is involved

  • If angular deformities result, corrective osteotomy may be necessary

• Torus fractures

  • Alignment is usually satisfactory, and simple immobilization for 3 weeks is sufficient

  • Soft bandage therapy and cast therapy are effective in preventing further angulation

  • It is important that the fracture is not misdiagnosed as a greenstick fracture at initial presentation;children who are misdiagnosed report having more pain after application of a soft bandage or cast

• Greenstick fractures

  • Reduction is achieved by straightening the ...